Apparatus and methods for facilitating treatment of tissue via improved delivery of energy based and non-energy based modalities

ABSTRACT

Methods and apparatus for accessing and treating regions of the body are disclosed herein. Using an endoscopic device having an automatically controllable proximal portion and a selectively steerable distal portion, the device generally may be advanced into the body through an opening. The distal portion is selectively steered to assume a selected curve along a desired path within the body which avoids contact with tissue while the proximal portion is automatically controlled to assume the selected curve of the distal portion. The endoscopic device can then be used for accessing various regions of the body which are typically difficult to access and treat through conventional surgical techniques because the device is unconstrained by “straight-line” requirements. Various applications can include accessing regions of the brain, thoracic cavity, including regions within the heart, peritoneal cavity, etc., which are difficult to reach using conventional surgical procedures.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.15/229,177 (filed Aug. 5, 2016), which is a continuation of U.S. patentapplication Ser. No. 13/962,264 (filed Aug. 8, 2013; now U.S. Pat. No.9,427,282), which is a divisional application of U.S. patent applicationSer. No. 10/850,360 (filed May 19, 2004; now U.S. Pat. No. 8,517,923),which is a continuation-in-part of U.S. patent application Ser. No.10/767,109 (filed Jan. 28, 2004; now abandoned), which was acontinuation in-part of U.S. patent application Ser. No. 10/228,583(filed Aug. 26, 2002; now U.S. Pat. No. 6,869,396), which is acontinuation of U.S. application Ser. No. 09/790,204 (filed Feb. 20,2001; now U.S. Pat. No. 6,468,203), which claims the benefit of priorityfrom U.S. Provisional Patent Application No. 60/194,140 (filed Apr. 3,2000), each of which is incorporated herein by reference in itsentirety.

FIELD OF THE INVENTION

The present invention relates generally to endoscopes and endoscopicmedical procedures. More particularly, it relates to methods andapparatus for accessing and treating regions within the body which aredifficult to reach through conventional surgical devices and procedures.

BACKGROUND OF THE INVENTION

Many surgical procedures typically require large incisions be made toprovide access to regions within the body. For instance, operating on ornear the posterior regions of the heart is ordinarily performed usingopen-chest techniques. Such a procedure generally requires a grossthoracotomy or sternotomy, which are both highly invasive and attendantwith a great deal of risks, such as ischemic damage to the heart,formation of emboli, etc. A thoracotomy typically involves creating anincision in the intercostal space between adjacent ribs while asternotomy involves the “chest spreader” approach, which is generallythe most invasive. Moreover, such an invasive procedure producessignificant morbidity, increased mortality rates, and significantlyincreases recovery time for the patient.

Minimally invasive surgery is an alternative surgical procedure in whichsmall incisions are made in the patient's body to provide access forvarious surgical devices for viewing and operating inside the patient.Laparoscopes are typically used for accessing and performing operationswithin the body through these small incisions using specially designedsurgical instruments. These instruments generally have handles which aremanipulatable from outside of the patient's body by the surgeon tocontrol the operation of the instrument typically through an elongatedtubular section which fits through a tube, introducer, or trocar deviceentering the patient's body.

However, even conventional laparoscopic procedures are limited inapplicability in part because of a “straight-line” requirement inutilizing laparoscopic tools. This requirement makes accessing certainareas within the body extremely difficult, if not impracticable.Moreover, the lack of flexibility of these tools have made access tocertain regions of the body difficult, forcing many surgeons to resortto open surgery rather than utilizing conventional minimally invasiveprocedures.

Flexible endoscopic devices are also available for use in minimallyinvasive surgical procedures in providing access to regions within thebody. Flexible endoscopes are typically used for a variety of differentdiagnostic and interventional procedures, including colonoscopy,bronchoscopy, thoracoscopy, laparoscopy and video endoscopy. A flexibleendoscope may typically include a fiberoptic imaging bundle or aminiature camera located at the instrument's tip, illumination fibers,one or two instrument channels that may also be used for insufflation orirrigation, air and water channels, and vacuum channels. However,considerable manipulation of the endoscope is often necessary to advancethe device through the body, making use of conventional devices moredifficult and time consuming and adding to the potential forcomplications.

Steerable flexible endoscopes have been devised to facilitate selectionof the correct path through regions of the body. However, as the deviceis typically inserted farther into the body, it generally becomes moredifficult to advance. Moreover, friction and slack in the endoscopetypically builds up at each turn, making it more difficult to advanceand withdraw the device. Another problem which may arise, for example,in colonoscopic procedures, is the formation of loops in the long andnarrow tube of the colonoscope. Such loops may arise when the scopeencounters an obstacle, gets stuck in a narrow passage, or takes on ashape that incorporates compound curves. Rather progressing, the scopeforms loops within the patient. In an attempt to proceed in insertion ofthe colonoscope, for example, excess force may be exerted, damagingdelicate tissue in the patient's body. The physician may proceed withthe attempted insertion of the endoscope without realizing there is aproblem.

Through a visual imaging device the user can observe images transmittedfrom the distal end of the endoscope. From these images and fromknowledge of the path the endoscope has followed, the user canordinarily determine the position of the endoscope. However, it isdifficult to determine the endoscope position within a patient's bodywith any great degree of accuracy.

None of the instruments described above is flexible enough to addressthe wide range of requirements for surgical procedures performedinternally to the patient's body. Furthermore, the instruments describedlack the ability to rotate the distal tip about the longitudinal axis ofthe instrument while fully articulating the tip to any setting relativeto the tubular section of the instrument. This lack of flexibilityrequires surgeons to manually rotate and move the instrument relative tothe patient body to perform the procedure.

BRIEF SUMMARY OF THE INVENTION

Endoscopic devices, as described below, may be particularly useful intreating various regions within the body. Such endoscopes may include asteerable distal portion and an automatically controlled proximalportion which may be controlled by a physician or surgeon to facilitatesteering the device while the proximal portion may be automaticallycontrolled by, e.g., a controller or computer. The steerable endoscopemay be advanced within the body of a patient, e.g., via any one of thenatural orifices into the body such as through the anus. Alternatively,the device may be introduced percutaneously through a small incisioninto the body. Once the endoscopic device has been introduced into thebody, it may be advanced and maneuvered to avoid obstructing anatomicalfeatures such as organs, bones, etc., without impinging upon the anatomyof the patient. Examples of such devices are described in detail in thefollowing patents and co-pending applications: U.S. Pat. Nos. 6,468,203;6,610,007; U.S. patent application Ser. No. 10/087,100 filed Mar. 1,2002; U.S. patent application Ser. No. 10/139,289 filed May 2, 2002,U.S. patent application Ser. No. 10/229,577 filed Aug. 27, 2002; U.S.patent application Ser. No. 10/229,814 filed Aug. 27, 2002, and U.S.patent application Ser. No. 10/306,580 filed Nov. 27, 2002, each ofwhich is incorporated herein by reference in its entirety.

Using such a device, one method of treating an obstructed region oftissue within a body, may generally comprise advancing an elongatedevice into the body through an opening, the elongate device having aproximal portion and a selectively steerable distal portion and theelongate device having a plurality of segments, selectively steering thedistal portion to assume a selected curve along a desired path withinthe body which avoids contact with tissue (or does not requiredisplacement of adjacent tissue along the desired path or avoidsapplying excess force to the adjacent tissue), and further advancing theelongate device through the body and towards the region of tissue to betreated while controlling the proximal portion of the device to assumethe selected curve of the distal portion.

Using any one of the controllable endoscopic devices, various regions ofthe body which are typically difficult to access and treat throughconventional surgical techniques, may be accessed and treatedaccordingly. In one treatment variation, the endoscopic device may beutilized for neurological surgical applications. Because the endoscopicdevice is unconstrained by “straight-line” requirements for accessingregions of the brain which are conventionally difficult to reach and/orbecause the device avoids forming loops when advanced, the endoscope maybe accurately advanced and positioned within the cranium by steering thedevice around the brain with minimal or no trauma to healthy braintissue. The endoscope may also be advanced through the tissue asnecessary to access treatment areas embedded deep within the tissuethrough pathways which may minimize any damage to healthy adjacenttissue. Furthermore, because the endoscopic device may allow access tosensitive regions over or within the brain, minimally invasive surgerymay be performed where conventional surgery would normally requireremoval of portions of the skull, for instance, in craniotomy proceduresor treatment of intracranial hematomas, etc. In addition, access throughthe nasal passages or other natural cranial orifices may be facilitated.

Another area of treatment in which the endoscopic device may be utilizedmay include use for coronary procedures, e.g., treatment of the mitralvalve, tissue ablation for the treatment of atrial fibrillation,placement, removal, or adjustment of pacing leads, etc. In one example,the endoscopic device may be introduced within the heart via thesuperior vena cava and advanced through the right atrium. Once theendoscope is within the right atrium, the distal portion may be steeredthrough the atrial septum and into the left atrium where the distalportion of the device may be positioned adjacent to the tissue to betreated, in this example, the mural valve. To affect treatment, varioustools or devices, e.g., scalpels, graspers, etc., may be deliveredthrough one or several working channels within the device to effect thetreatment.

In yet another area of treatment in which the endoscopic device may beutilized, various thoracoscopy procedures may be accomplished in aminimally invasive procedure, e.g., percutaneously. As shown, theendoscope may be advanced into the patient via an introducer or port,which may also be configured as a datum for establishing a fixed pointof reference for the endoscope during the procedure. The port or datummay be in electrical communication with a computer or processor used fordetermining and/or maintaining the position of the device within thepatient. The endoscope may be advanced into the body of the patientthrough an incision made, e.g., in the intercostal space between theribs. The endoscope may then be advanced into the thoracic cavity andmaneuvered to regions within the body such as the posterior region ofthe heart which are normally inaccessible for conventional laparoscopicprocedures due to a lack of straight-line access.

One embodiment of the present invention provides a method forfacilitating a treatment within a body including inserting an endoscopehaving a steerable distal end and a controllable proximate end, thecontrollable proximate end being controlled to follow the steerabledistal end. The endoscope is maneuvered into a position within the bodyto facilitate a treatment of a body portion. A treatment is performed onthe body portion. The body portion could be, for example, in thethoracic cavity, the skull, or the peritoneal cavity.

Another embodiment of the present invention provides a system forperforming a treatment of a condition related to a physiologicalindication within a body. There is a system for detecting and localizinga physiological indication within the body. A system for providingimaging of a portion of the body related to the physiological indicationwithin the body. A steerable endoscope having a steerable distal end anda controllable proximate end under the control of a computer controllerthat receives information from the system for detecting and the systemfor providing.

Another embodiment of the present invention provides a system forfacilitating a treatment of the heart having a system for indicating thelocation of an errant condition of the heart. There is also provided acontroller system utilizing information generated by the system forindicating to assist in the articulation of a steerable endoscope havinga steerable distal end and a controllable proximate end to follow thesteerable distal end into a position to facilitate a treatment of theerrant condition of the heart. In addition, there is provided atreatment device provided by the steerable endoscope to perform atreatment of the errant condition of the heart.

In another embodiment of the present invention, there is provided anapparatus for performing a cardiac ablation therapy having a steerableendoscope having a steerable distal end and a controllable proximate endconfigured to automatically follow the configuration of the steerabledistal end. An ablation therapy device adapted to be deployed by thesteerable endoscope. A fastener that fixes the position of the ablationtherapy device.

Another embodiment of the present invention provides a method ofperforming a treatment within the body by advancing a steerable distalend of an endoscope along a pathway into a treatment position tofacilitate a treatment within a body. The proximate end of the endoscopeis controlled to follow the pathway of the steerable distal end of theendoscope. A treatment element is provided to the treatment position.

embodiment of the present invention utilizes a pair of steerableendoscopes to deliver a therapy within the body. The pair of endoscopesmay be arranged such that one endoscope is within the other endoscopeor, alternatively, where one endoscope is adjacent the other endoscope.In another embodiment, one steerable endoscope may be maneuvered into adesired position within the body to facilitate treatment and then fixedinto that position. Thereafter, the second endoscope may be maneuveredto perform the therapy or facilitate a treatment utilizing the fixedposition within the body provided by the first endoscope. This proceduremay be useful in conditions of movement, such as beating hearttreatments where the first endoscope may be used as a fixed treatmentpoint for utilizing the second endoscope.

The endoscope device may also be utilized for procedures within theperitoneal cavity. Potential applications may include minimally invasivesurgery for urologic, bariatric, and liver surgery. Moreover, minimallyinvasive access may be achieved for treatments in spinal or orthopedicsurgery as well. In such a procedure, the endoscope may be introducedinto the patient through an incision via a port, which may also functionas a datum. The distal portion may be steered to avoid various organswhile being advanced to a tissue region to be treated, e.g., the liver.The distal portion of the endoscope may accordingly be steered while theproximal portion may be automatically controlled to follow a pathdefined by the distal portion which minimizes contact with thesurrounding and adjacent tissue and organs. In this or any otherprocedure, one or more laparoscopes may optionally be used incombination with the endoscope to assist with the surgical procedure.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows one variation of a steerable endoscope which may beutilized for accessing various regions within the body without impingingupon the anatomy of the patient.

FIG. 2A shows a wire frame model of a section of the elongate body ofthe endoscope in a neutral or straight position.

FIG. 2B shows an illustration of the endoscope body maneuvered through acurve with the selectively steerable distal portion and automaticallycontrolled proximal portion.

FIG. 3 shows a cross-sectional side view of a patient's head with avariation of the endoscope being advanced therethrough.

FIG. 4 shows the interaction of several components to provide a methodof positioning a steerable endoscope system to facilitate treatment.

FIG. 5 shows a cross-sectional anterior view of a heart with theendoscopic device introduced via the superior vena cava and advanced tothe right atrium.

FIG. 6 shows an example of a thoracoscopy procedure which may beperformed percutaneously with the endoscopic device.

FIGS. 7A, 7B, 7C, and 7D progressively show an example of the endoscopicdevice being advanced about the posterior region of a heart tofacilitate treatment of a supraventricular tachycardia.

FIGS. 8A, 8B, 8C, and 8D progressively show an example of the endoscopicdevice being advanced about the posterior region of a heart andretracted to deploy a device to facilitate treatment of asupraventricular tachycardia.

FIG. 9 shows an embodiment of a treatment device having a plurality offasteners to facilitate contact between the treatment device and thesurrounding tissue.

FIGS. 10A and 10B show additional examples of the endoscopic deviceadvanced about the posterior region of a heart to facilitate treatmentof a supraventricular tachycardia (FIG. 10A) and a combination ofsupraventricular and ventricular tachycardia (FIG. 10B).

FIG. 11 shows yet another example of a treatment for atrial fibrillationusing the endoscopic device.

FIGS. 12A, 12B, 12C, and 12D show additional examples of the endoscopicdevice advanced about the posterior region of a heart to facilitatetreatment of a supraventricular tachycardia and/or combinations ofsupraventricular and ventricular tachycardia.

FIG. 13 shows an embodiment of a dual, steerable endoscope of thepresent invention utilized to facilitate treatment of the heart.

FIGS. 14A, 14B, and 14C show side and end views, respectively, ofvarious electrode configurations on the endoscope for tissue ablationtreatment.

FIGS. 15A and 15B show an embodiment of a needle array in a retracted(FIG. 15A) and a deployed (FIG. 15B) configuration.

FIG. 16 shows an embodiment of a needle array having a continuousspacing.

FIG. 17 shows an embodiment or a needle array having a variety ofspacing configurations.

FIGS. 18A and 18B show a side and isometric view of an embodiment of atreatment device of the present invention.

FIGS. 18C and 18D show a plurality of the treatment devices in optimizedpositions for facilitating a therapy.

FIG. 19 shows a graph illustrating a technique to optimize placement ofa device to facilitate therapy.

FIG. 20 shows an example of a procedure within the peritoneal cavitywhich may be performed with the endoscopic device.

DETAILED DESCRIPTION OF THE INVENTION

In treating various regions within the body, a number of differentendoscopic devices may be utilized in facilitating access. Endoscopicdevices which are particularly useful may include various endoscopeshaving a steerable distal portion and an automatically controlledproximal portion. Generally, the steerable distal portion may becontrolled by a physician or surgeon to facilitate steering the devicewhile the proximal portion may be automatically controlled by, e.g., acontroller or computer. The steerable endoscope may be advanced withinthe body of the patient through a number of different methods. Forinstance, the endoscope may be introduced via anyone of the naturalorifices into the body such as through the anus. Alternatively, thedevice may be introduced percutaneously through a small incision intothe body. Once the endoscopic device has been introduced into the body,it may be advanced and maneuvered, as described below, to avoidobstructing anatomical features such as organs, bones, etc., withoutimpinging upon the anatomy of the patient.

FIG. 1 illustrates one variation of a steerable endoscope 100 which maybe utilized for accessing various regions within the body withoutimpinging upon the anatomy of the patient. The endoscope 100 generallyhas an elongate body 102 with a manually or selectively steerable distalportion 104 and an automatically controlled proximal portion 106. Theselectively steerable distal portion 104 may be selectively steered orbent up to a full 180° bend in any direction, as shown by the dashedlines. A fiberoptic Imaging bundle 112 and one or more illuminationfibers 114 may optionally be extended through the body 102 from theproximal end 110 to the distal end 108. Alternatively, the endoscope 100may be configured as a video endoscope with a miniaturized video camera,such as a CCD or CMOS camera, positioned at the distal end 108 of theendoscope body 102. The images from the video camera may be transmittedto a video monitor by a transmission cable or by wireless transmission.Optionally, the body 102 of the endoscope 100 may also include at leastone or two instrument channels 116, 118 that may be used to provideaccess through the endoscope for any number of tools. Channels 116, 118may also be used for various other purposes, e.g., insufflation orirrigation.

The elongate body 102 of the endoscope 100 is highly flexible so that itis able to bend around small diameter curves without buckling orkinking. The elongate body 102 of the endoscope 100 may range in lengthtypically from, e.g., 135 to 185 cm, and 12 to 13 mm in diameter.However, if the endoscope 100 were utilized in regions within the bodywhich are smaller than the space within, e.g., the gastrointestinaltract, the device may be modified in size to be small in diameter. Theendoscope 100 may also be modified in length to be longer or shorter,depending upon the desired application.

A handle 120 is attachable to the proximal end 110 of the elongate body102. The handle 120 may include an ocular 124 connected to thefiberoptic imaging bundle 112 for direct viewing and/or for connectionto a video camera 126. The handle 120 may also be connected to anillumination source 128 via an illumination cable 134 that may beconnected to or continuous with the illumination fibers 114. An optionalfirst luer lock fitting 130 and an optional second luer lock fitting132, which may be in communication with instrument channels 116, 118,respectively, may also be located on or near the handle 120.

The handle 120 may be connected to an electronic motion controller 140by way of a controller cable 136. A steering control 122 may beconnected to the electronic motion controller 140 by way of a secondcable 138. The steering control 122 may configured to allow thephysician or surgeon to selectively steer or bend the selectivelysteerable distal portion 104 of the elongate body 102 in the desireddirection. The steering control 122 may be a joystick controller asshown, or other known steering control mechanism. Alternatively, thesteering may be effected manually, e.g. by the use of cables,hydraulics, or pneumatics, or any other known mechanical apparatus forcontrolling the distal portion of the elongate body. The electronicmotion controller 140 may be used to control the motion of theautomatically controlled proximal portion 106 of the elongate body 102and may be implemented using a motion control program running on amicrocomputer or through an application-specific motion controller.Alternatively, the electronic motion controller 140 may be implementedusing a neural network controller.

An axial motion transducer 150 may be provided to measure the axialmotion of the elongate body 102 as it is advanced and withdrawn. Theaxial motion transducer 150 can be made in many configurations, some ofwhich are described below. In this variation, the axial motiontransducer 150 is configured as a ring 152, for illustrative purposesonly, that surrounds the elongate body 102 of the endoscope 100. Theaxial motion transducer 150 may be attached to a fixed point ofreference, such as the surgical table or the insertion point for theendoscope 100 on the patience's body, as described below. As the body102 of the endoscope 100 slides through the axial motion transducer 150,it produces a signal indicative of the axial position of the endoscopebody 102 with respect to the fixed point of reference and sends a signalto the electronic motion controller 140 by telemetry or by a cable (notshown). The axial motion transducer 150 may use optical, electronic,magnetic, mechanical, etc., methods to determine the axial position ofthe endoscope body 102. In addition, the motion transducer may beconfigured to simultaneously measure and communicate rotational motionof the endoscope, so that this additional data may be used in thecontrol of the instrument's motion. A further detailed description ofthe axial motion transducer 150 and variations thereof may be found inU.S. patent application Ser. No. 10/384,252 filed Mar. 7, 2003, which isincorporated herein by reference in its entirety.

To illustrate the basic motion of the steerable endo scope 100, FIG. 2Ashows a wire frame model of a section of the body 102 of the endoscope100 in a neutral or straight position. Most of the internal structure ofthe endoscope body 102 has been eliminated in this drawing for the sakeof clarity. The endoscope body 102 is divided up into sections 1, 2, 3 .. . 10, etc. The geometry of each section is defined by four lengthmeasurements along the a, b, c and d axes. For example, the geometry ofsection 1 may be defined by the four length measurements 1_(1a), 1_(1b),1_(1c), 1_(1d), and the geometry of section 2 may be defined by the fourlength measurements 1_(2a), 1_(2b), 1_(2c), 1_(2d), etc. The geometry ofeach section may be altered using the linear actuators to change thefour length measurements along the a, b, c and d axes. For example, tobend the endoscope body 102 in the direction of the a axis, themeasurements 1_(1a), 1_(2a), 1_(3a) . . . 1_(10a) can be shortened andthe measurements 1_(1b), 1_(2b), 1_(3b) . . . 1_(10b) can be lengthenedan equal amount. The amount by which these measurements are changeddetermines the radius of the resultant curve. In automaticallycontrolled proximal portion 106, however, the a, b, c and d axismeasurements of each section may be automatically controlled by theelectronic motion controller 140.

In FIG. 2B, the endoscope body 102 has been maneuvered through the curveC with the benefit of the selectively steerable distal portion 104 andnow the automatically controlled proximal portion 106 resides in thecurve C. Sections 1 and 2 are in a relatively straight part of the curveC, therefore 1_(1a)=1_(1b) and 1_(2a)=1_(2b). However, because sections3-7 are in the S-shaped curved section, 1_(3a)<1_(3b), 1_(4a)<1_(4b) and1_(5a)<1_(5b), but 1_(6a)>1_(6b), 1_(7a)>1_(7b) and 1_(8a)>1_(8b). Whenthe endoscope body 102 is advanced distally by one unit, section 1 movesinto the position marked 1′, section 2 moves into the positionpreviously occupied by section 1, section 3 moves into the positionpreviously occupied by section 2; etc. The axial motion transducer 150produces a signal indicative of the axial position of the endo scopebody 102 with respect to a fixed point of reference and sends the signalto the electronic motion controller 140. Under control of the electronicmotion controller 140, each time the endoscope body 102 advances oneunit, each section in the automatically controlled proximal portion 106is signaled to assume the shape of the section that previously occupiedthe space that it is now in. Therefore, when the endoscope body 102 isadvanced to the position marked 1′, 1_(1a)=1_(1b), 1_(2a)=1_(2b),1_(3a)=1_(3b), 1_(4a)<1_(4b), 1_(5a)<1_(5b), 1_(6a)<1_(6b),1_(7a)>1_(7b), 1_(8a)>1_(8b), and 1_(9a)>1_(9b), and, when the endoscopebody 102 is advanced to the position marked 1″, 1_(1a)=1_(1b),1_(2a)=1_(2b), 1_(3a)=1_(3b), 1_(4a)=1_(4b), 1_(5a)<1_(5b),1_(6a)<1_(6b), 1_(7a)<1_(7b), 1_(8a)>1_(8b), 1_(9a)>1_(9b), and1_(10a)>1_(10b). Thus, the S-shaped curve propagates proximally alongthe length of the automatically controlled proximal portion 106 of theendoscope body 102. The S-shaped curve appears to be fixed in space, asthe endoscope body 102 advances distally.

Similarly, when the endoscope body 102 is withdrawn proximally, eachtime the endoscope body 102 is moved proximally by one unit, eachsection in the automatically controlled proximal portion 106 is signaledto assume the shape of the section that previously occupied the spacethat it is now in. The S-shaped curve propagates distally along thelength of the automatically controlled proximal portion 106 of theendoscope body 102, and the S-shaped curve appears to be fixed in space,as the endoscope body 102 withdraws proximally.

Whenever the endoscope body 102 is advanced or withdrawn, the axialmotion transducer 150 may be used to detect the change in position andthe electronic motion controller 140 may be used to propagate theselected curves proximally or distally along the automaticallycontrolled proximal portion 106 of the endoscope body 102 to maintainthe curves in a spatially fixed position. Similarly, if the endoscope102 is rotated, a rotational motion transducer (separate from orintegrated within transducer 150) may be used to detect the change inposition and the electronic motion controller may be similarly used toadjust the shape of the endoscope body 102 to maintain the curves in aspatially fixed position. This allows the endoscope body 102 to movethrough tortuous curves without putting unnecessary force on the wall ofthe curve C.

Examples of other endoscopic devices which may be utilized in thepresent invention are described in further detail in the followingpatents and co-pending applications, U.S. Pat. Nos. 6,468,203;6,610,007; U.S. patent application Ser. No. 10/087,100 filed Mar. 1,2002; U.S. patent application Ser. No. 10/139,289 filed May 2, 2002,U.S. patent application Ser. No. 10/229,577 filed Aug. 27, 2002; U.S.patent application Ser. No. 10/229,814 filed Aug. 27, 2002, and U.S.patent application Ser. No. 10/306,580 filed Nov. 27, 2002, each ofwhich has been incorporated herein by reference above.

Therefore, using anyone of the controllable endoscopic devices describedabove, various regions of the body which are typically difficult toaccess and treat through conventional surgical techniques, may beaccessed and treated accordingly. In one treatment variation, theendoscopic device may be utilized for neurological surgicalapplications. Because the endoscopic device is unconstrained by“straight-line” requirements for accessing regions of the brain whichare conventionally difficult to reach, the endoscope may be advanced andpositioned within the cranium by steering the device around the brainwith minimal or no trauma to healthy brain tissue. The endoscope mayalso be advanced through the tissue as necessary to access treatmentareas embedded deep within the tissue through pathways which mayminimize any damage to healthy adjacent tissue. Furthermore, because theendoscopic device may allow access to sensitive regions over or withinthe brain, minimally invasive surgery may be performed whereconventional surgery would normally require removal of portions of theskull, for instance, in craniotomy procedures or treatment ofintracranial hematomas, etc.

FIG. 3 shows a cross-sectional side view of head 202 of patient 200. Thebrain 206 may be seen within the cranial cavity 210 of cranium 204. Theendoscopic device 212 is an embodiment of a steerable endoscope of thepresent invention that has been sized, shaped and configured foraccessing the interior of the cranial cavity and external and internalregions of the brain. The movement, position, tracking and control ofthe endoscopic device 212 is performed by a user alone or in cooperationwith any or all of imaging systems, position and location systems, andsurgical planning methods and techniques. In treating regions of thebrain 206 which may be difficult to normally access, the endoscopicdevice 212 may be introduced into the cranial cavity 210 from an easilyaccessible insertion site 222, e.g., a perforation within the skull. Theendoscope 212 may be then advanced through the insertion site 222 bycontrolling the steerable distal portion 214 to avoid brain tissue. Asthe endoscope 212 is further advanced into the cranial cavity 210, theautomatically controlled proximal portion 216 may attain the shapedefined by the steerable distal portion 214 to avoid contact with braintissue 206.

The endoscope 212 may be further advanced through the cranial cavity 210and within the cerebrospinal fluid so that the device is advanced aboveor within the layers of the meninges, e.g., within the subarachnoidspace. In either case, the endoscope 212 may be steered along a pathwhich avoids or minimizes contact or pressure against the brain tissue206. As the proximal portion 216 is advanced distally and attains theshape defined by the distal portion 214, the proximal portion 216likewise may be controlled to automatically avoid or minimize contact orpressure against the brain tissue 206. Once the distal portion 216 isadvanced to the desired treatment region 208, various tools 220 may beintroduced through the instrument channel 218 to enable treatment of theregion 208. Any number of treatments or procedures may accordingly beeffected, e.g., tumor biopsy and/or removal, shunt placement, leadplacement, device placement, drainage of excess cerebrospinal fluid orblood, etc.

FIG. 4 shows the interaction of several components to provide a methodof positioning a steerable endoscope system to facilitate treatment. Asmentioned above, the movement, position, tracking and control ofendoscopic devices according to the present invention is performed by auser alone or in cooperation with any or all of imaging systems,position and location systems, and surgical planning methods andtechniques. The system schematic 4000 illustrates one embodiment of anintegrated detection, mapping and control system for positioning andcontrolling a steerable, controllable endoscope of the presentinvention. First, a suitable device, element or system is used to detectand localize a physiological indication (4010). A physiologicalindication could be any perceptible indicia of a condition for whichtreatment may be facilitated. In a coronary example, physiologicalindicators include electrophysiology data or electrical signals from theheart. This system would be capable of identifying or performinganalysis of monitored data to identify or determine the location oferrant activity.

Next, information regarding the detected and localized physiologicalindication is passed to an image/mapping system (4020). An image/mappingsystem includes any imaging modality that may provide position,location, tissue type, disease state, or any other information thatfacilitates correlating the physiological activity to an identifiableand/or localizable position within the anatomy or within a frame ofreference. Examples of image/mapping systems include any of the imagingtechnologies such as x-ray, fluoroscopy, computed tomography (CT), threedimensional CAT scan, magnetic resonance imaging (MRI), and magneticfield locating systems. Examples of image/mapping systems specificallysuited for the treatment of cardiovascular disorders includeelectrocardiogram detection systems, cardiac electrophysiology mappingsystems, endocardial mapping systems, or other systems and methods thatprovide the ability acquire, visualize, interpret and act on cardiacelectrophysiological data. An example of such a system is described inU.S. Pat. No. 5,848,972 entitled, “Method for Endocardial ActivationMapping Using a Multi-Electrode Catheter” the entirety of which isincorporated herein by reference. Additional examples are described inU.S. Pat. Nos. 5,487,385; 5,848,972; and 5,645,064, the entirety of eachof these patents is incorporated by reference. Integrated mapping,detection and/or ablation probes and devices may also be delivered usingthe steerable endoscope of the present invention. One such integratedsystem is described in US Patent Application Publication US 2003/0236455to Swanson et al the entirety of which is incorporated herein byreference. Additional other systems may provide mapping, display orposition information of a local isochronal activation map of the heartalong with the relative position of the endoscope and directioninformation or movement commands to position the endoscope (orcomponents, elements or systems onboard the endoscope) to providetreatment to the source of the arrhythmia.

Next, information provided, compiled and/or analyzed in the prior stepsor other additional information provided by a user or other system usedby the user is input into or utilized by the endoscope controller(4030). This step indicates the ability of the endoscope controller torespond to the indication, position, image, mapping and other data andutilize that data for altering the scope configuration, position,orientation or other relational information indicative of the scopecontroller responding to the information provided. The endoscope isconfigured to provide of facilitate providing components, elements orsystems to facilitate a treatment of the physiological indication beingmonitored. The controller utilizes the data provided to position thesteerable, controllable endoscope into a position related to thelocation or site that exhibits the errant activity. The proximity of theendoscope to the location or site of the errant activity will varydepending upon, for example, the treatment being implemented, theelement, component or system being used to facilitate treatment.

Finally, the position of the endoscope is supplied back into the imageor mapping system as a form of feedback to better assist in guiding theendoscope into the desired position to facilitate treatment (4040).

In another embodiment, the system 4000 may include an overall mappingsystem that provides medically significant data that facilitates atreatment. This overall mapping or imaging system may include mapping orimaging an area of monitored activity. The area of monitored activityincludes not only the portion of the body important to the treatment butalso imaging information of those other parts of the body not impactedby the treatment but are instead the likely pathway(s) of the steerable,controllable endoscope to reach the area where the treatment will befacilitated. In addition, some embodiments of the system may include theability to detect, localize or otherwise indicate the position of thetreatment area or area of errant activity or conditions subject totreatment. These indications may then be utilized to augment theguidance of the steerable, controllable endoscope into the desiredposition to facilitate treatment. In addition, other medical imaging andtracking systems may be utilized to provide tracking, guidance andposition feedback information to the control of the steerable endoscope.An exemplary system is described by Dumoulin et al. in U.S. Pat. No.5,377,678 which is incorporated herein by reference in its entirety.

The above steps are only representative of one embodiment of howphysiological indications, and position information may be utilized toimprove the guidance system and controls used by steerable endoscopes toensure the placement of the endoscope to facilitate treatment. It is tobe appreciated that the steps were utilized for clarity and ease ofdiscussion. The methods of embodiments of the invention are not solimited. For example, a single system could be used as an integratedindication, imaging, endoscope controller that receives endoscopeposition feedback in real time. In an alternative example, thephysiological indication and image/mapping functions may be combinedinto a single unit. As such, while the above steps have been describedas happening only once or in a serial fashion, it is to be appreciatedthat the steps may be conducted in as different order or multiple times.Other physiological indication detection and localization systems may beused and will correspond to an appropriate system useful in thetreatment being performed. In addition, alternative image and mappingsystems may also be employed and may also be selected depending upon thetreatment being facilitated through the use of a steerable controllableendoscope of the present invention. The system may also control themovement of the endoscope automatically based on inputs from the user,pre-surgical planning data, or other indications of desired pathways orpathways to avoid. Alternatively, or in addition, a user may inputadditional guidance or control information into the system forfurthering the guidance or desired placement of the endoscope.

Another area of treatment in which the endoscopic device may be utilizedmay include use for coronary procedures, e.g., treatment of the mitralvalve, performing or facilitating treatment of supraventriculartachycardia, including, for example, tissue ablation for the treatmentof atrial fibrillation, treatment of ventricular tachycardia alone or incombination with treatment of supraventricular tachycardia, treatmentsfor the placement, repositioning or removal of device leads, etc. Atrialfibrillation is typically sustained by the presence of multipleelectrical reentrant wavelets propagating simultaneously in the atria ofthe heart. Surgical and catheter-based techniques typically placesegmented or continuous lesions near and around the pulmonary veins asone way to re-synchronize the atria.

In addition, a variety of ablation techniques using energy based andnon-energy based modalities may be utilized to ablate soft tissue.Embodiments of the present invention may be utilized to facilitateablation therapies, ablation elements and devices that employ one or acombination of energy modalities, such as, for example, cryogenicenergy, hydraulic energy, laser energy, magnetic energy, mechanicalenergy, microwave energy, radiation energy, radio-frequency energy,thermal energy, and ultrasonic energy. Microwave ablation systems mayinclude, for example, those based on AFx microwave surgical ablationsystems such as the AFx Flex 4 or the like. AFx is currently owned byGuidant Corp. Cryogenic ablation systems may include, for example,systems available from Cryocath Technologies such as the “SurgiFrost,”“Frostbyte” or “Artic Circler” systems and the like. Ultrasound basedsurgical probes may be, for example, based upon the ultrasound ablationsystems produced by EpiCor Medical or the like. A large number ofcommercially available ablation systems are available to illustrate thewide variety of ablation systems, techniques and modalities that may bedelivered or utilized by embodiments of the steerable endoscopic systemsof the present invention.

As shown in FIG. 5, a cross-sectional anterior view of heart 302 may beseen in coronary procedure 300 for treatment of the mitral valve MVlocated between the left atrium LA and the left ventricle LV. Theendoscopic device 212 is shown in this treatment variation as beingintroduced within the heart 302 via the superior vena cava SVC andadvanced through the right atrium RA. Also shown is the right ventricleRV below the tricuspid valve TV and inferior vena cava IVC. Theendoscope 212 may be sized accordingly to be delivered intravascularly.Once the endoscopic device 212 is within the right atrium RA, the distalportion 214 may be steered towards the atrial septum AS which separatesthe left atrium LA and right atrium RA. Once at the atrial septum AS, acutting tool deliverable through the device 212 may be used to perforatethe atrial septum AS to allow passage of the endoscopic device 212 intothe left atrium LA. The distal portion 214 may then be steered andpositioned adjacent the mitral valve MV while the proximal portion 216is automatically controlled to minimize any pressure which may beexerted by the device 212 against the tissue of the heart 302. Once theendoscopic device is adjacent to the tissue to be treated, in thisexample the mitral valve MV, various tools or devices may be deliveredthrough the channel 218 to effect the treatment. Once the procedure hasbeen completed, the endoscope 212 may simply be withdrawn proximally inthe same manner while minimizing any contact pressure against thetissue.

In yet another area of treatment in which the endoscopic device may beutilized, various thoracoscopy procedures may be accomplished in aminimally invasive procedure. FIG. 6 shows an example of a thoracoscopyprocedure 400 which may be performed percutaneously. As shown, theendoscope 212 may be advanced into the patient 402 via an introducer orport 412, which may also be configured as a datum for establishing afixed point of reference for the endoscope 212 during the procedure. Theport or datum 412 may be in electrical communication via electricallines 418 with a computer or processor 416 which may be used fordetermining and/or maintaining the position of the device 212 within thepatient 402. The endoscope 212 may be advanced into the body of thepatient 402 through an incision 414 made, e.g., in the intercostal spacebetween the ribs 404. The endoscope 212 may then be advanced into thethoracic cavity and maneuvered to regions within the body such as theposterior region of the heart 408 which are normally inaccessible forconventional laparoscopic procedures due to a lack of straight-lineaccess.

In this example, the endoscopic device 212 is shown having been insertedthrough port or datum 412 and advanced posteriorly of heart 408 behindsternum 406. The lungs are not shown for the sake of clarity; however,the endoscope 212 may be steered and advanced around the lungs in amanner described above so as to avoid contact or to minimize contactwith the lung tissue or any other organs or structures which may beobstructing a straight-line path.

The endoscopic device 212 is capable of reaching regions within thebody, without damaging surrounding tissue, which is normallyinaccessible via conventional laparoscopic procedures. FIGS. 7A to 7Dshow an example of the endoscopic device advanced about the posteriorregion of a heart to facilitate treatment of a supraventriculartachycardia. One example of a supraventricular tachycardia is atrialfibrillation. Another procedure 500 is shown in FIGS. 7A to 7D, whichillustrate how the endoscopic device may be utilized for the treatmentof atrial fibrillation. The figures show a posterior view of the heartwith the aorta AA and pulmonary trunk PT as anatomical landmarks. Atrialfibrillation is typically sustained by the presence of multipleelectrical reentrant wavelets propagating simultaneously in the atria ofthe heart. Surgical and catheter-based techniques typically placesegmented or continuous lesions near and around the pulmonary veins asone way to re-synchronize the atria.

The endoscopic device 212 may be utilized by advancing the device 212into the thoracic cavity, as described above or through various otherchannels, and steered towards the posterior region of the heart. In theexample shown in FIGS. 7A to 7D, the steerable distal portion 214 may beadvanced as shown in FIG. 7A such that the endoscope 212 approachesabove the left pulmonary veins LPV. As shown in FIG. 7B, the distalportion 214 may be steered around the right pulmonary veins RPV whilethe endoscope 212 is advanced distally. The automatically controllableproximal portion 216 may thus assume the shape defined by the distalportion 214 in traversing around the pulmonary vessels. As shown in FIG.7C, the distal portion 214 is steered around the left pulmonary vesselsLPV while the proximal portion has assumed the curved path traversed bythe device around the right pulmonary vessels RPV. Finally in FIG. 7D,the device 212 may be fully advanced entirely around the pulmonaryvessels such that the distal portion 214 and proximal portion 216 are inintimate contact against the heart tissue while maintaining itsconfiguration. The tissue which is in contact against the device 212 maythen be ablated by one or several electrodes located along the length ofthe distal and/or proximal portions 214, 216, as described in furtherdetail below. Alternately, an ablation device such as a catheter orother energy source, may be delivered through one or more workingchannels in or on the endoscope, and left in place as desired. Thisablation device may then be used to deliver ablative energy in variousforms, e.g., RF, microwave, cryogenic cooling, etc., as described hereinor known to those of ordinary skill in the art. The device may be heldfixedly in the desired location by various methods, e.g., vacuum,magnetically, temporary adhesives, sutures, or any other methods ofattaching or approximating the device and tissue.

FIGS. 8A to 8D show an example of a procedure 600 wherein a steerableendoscopic device is advanced about the posterior region of a heart andthen retracted to deploy a device to facilitate treatment of asupraventricular tachycardia. The steerable endoscopic device 800 iscapable of reaching regions within the body as described above and as animprovement over laparoscopic procedures. The figures show a posteriorview of the heart with the aorta AA and pulmonary trunk PT as anatomicallandmarks. FIG. 8A illustrates an endoscopic device 800 having asteerable, controllable distal end 805 and a controllable proximal end810. In FIG. 8A, at the beginning of the procedure 600 the endoscopicdevice 800 has been maneuvered into position to initiate deployment ofan ablation device 815. It is to be appreciated that in this exemplaryprocedure 600 the steerable endoscopic device 800 has been maneuvered tothe initial deployment point by tracing out a desired deployment ortreatment pathway about the pulmonary veins. While illustrated withregard to the pulmonary veins for purposes of the discussion ofprocedure 600, the utilization of the steerable endoscope is not solimited and may be used to trace out desired treatment pathways aboutorgans, tissues and body portions as desired. FIG. 8A also illustratesthe ablation device 815 distal end is attached to the heart using any ofthe attachment methods described in this application or known to thoseof ordinary skill in the art.

Next, in FIGS. 8B and 8C, the steerable endoscope 800 is withdrawnproximally along the pathway leaving behind the ablation device 815.Finally, in FIG. 8D, the ablation device 815 is completely deployedabout the pulmonary veins in the desired deployment pathway created bythe steerable endoscope 800. At this point a number of options areavailable in procedure 600. The endoscope 800 may be withdrawn duringthe treatment that utilizes the ablation device 815. The endoscope 800may be utilized to visually inspect the position and orientation of eachablation element distributed along the ablation device 815 in thoseembodiments where the ablation device 815 comprises a plurality ofablation elements. In this illustrated embodiment, the ablation device815 has been illustrated as a single ablation element for ease ofillustration. The endoscope may also be utilized to ensure the ablationdevice 815 has been properly deployed into the desired position tofacilitate treatment. In addition, the endoscope may be utilized tovisually inspect any fasteners or other adhesives or affixing means usedto maintain the position of the ablation device 815 relative to thepulmonary veins.

FIG. 9 shows an embodiment of a treatment device having a plurality offasteners to facilitate contact between the treatment device and thesurrounding tissue. An endoscopic device 900 has a controllable,steerable end 905 positioned to deploy or facilitate the deployment ofan ablation device 915. The ablation device 915 has a plurality ofablation elements 920. The ablation device 915 also has a plurality offasteners 925 to increase the contact between the ablation device 915and the surrounding tissue, organ or body portion to facilitate ablationtherapy. Note the position of the fasteners 925 relative to the ablationelements 920 to provide maximum contact between and to ensure thelocation of the ablation elements 920 relative to the surroundingtissue. The fasteners 925 may be in other positions and may also be ofother configurations and type described elsewhere in this applicationand/or as known to those of ordinary skill in the art.

In another embodiment of the steerable endoscope 900, the fasteners 925could be configured such that as the steerable tip 905 is withdrawnproximally, the fastener 925 engages the surrounding tissue to securethe position of the ablation device 915. Once the ablation device 915 ispositioned, the ablation treatment proceeds as desired. When theablation treatment is complete, the steerable endoscope 900 is advancesproximally from the distal end of the ablation device 915. As thesteerable endoscope tip 905 advances distally past a fastener 925, thefasteners 925 along with the ablation device 915 are withdrawn into thesteerable endoscope 900. It is to be appreciated that any of a widevariety of fasteners may be utilized to engage with the surroundingtissue. For example, the fasteners 925 could be formed from superelasticor shape memory alloy material. The properties of the shape memory alloymaterial could be selected such that the thermal energy of the bodytemperature is used to engage the fastener with the surrounding tissue.Alternatively, the shape memory alloy fasteners could be selectivelyactuated to release the shape memory effect to engage with thesurrounding tissue. Engagement with the tissue includes fasteners thatdo not break the surface of the tissue as well as fasteners that dobreak the surface of the tissue. While some fasteners may disengage fromthe surrounding tissue through the movement of the steerable endoscope,it is to be appreciated that a tool or element may be present on or inthe distal end of the endoscope 900 to facilitate the disengagement ofthe fastener from the surrounding tissue.

FIGS. 10A and 10B show additional examples of the endoscopic deviceadvanced about the posterior region of a heart to facilitate treatmentof a supraventricular tachycardia (FIG. 10A) and a combination ofsupraventricular and ventricular tachycardia (FIG. 10B). In a specificexample, FIG. 10A shows another variation 600 of treating atrialfibrillation where the device may be steered and configured to loop in acontinuous manner about the pulmonary vessels in a first encirclement602 over the left pulmonary vessels LPV and a second encirclement 604over the right pulmonary vessels RPV. The encircled portions 602, 604 ofthe endo scope 212 may be activated to ablate the heart tissue onlyaround the pulmonary vessels LPV, RPV or alternatively, it may beactivated to ablate the heart tissue along the entire length of bothdistal portion 214 and proximal portion 216. Moreover, a variety ofablation devices may be delivered to the desired areas, as describedabove.

In another specific example, FIG. 10B shows another variation 650 oftreating atrial fibrillation where the device may be steered andconfigured to loop in a continuous manner about the pulmonary vessels ina first encirclement 602 over the left pulmonary vessels LPV and asecond encirclement 652 over the right pulmonary vessels RPV and thenacross a portion of the ventricle (654). The encircled portions 602,652, 654 of the endoscope 212 may be activated to ablate the hearttissue around the pulmonary vessels LPV, RPV and the ventricular portionadjacent 654. Alternatively, it may be activated to ablate the hearttissue along the entire length of both distal portion 214 and proximalportion 216. Moreover, a variety of ablation devices may be delivered tothe desired areas, as described above.

FIG. 11 shows yet another example of a treatment for atrial fibrillationusing the endoscopic device. In a specific embodiment, FIG. 11 shows yetanother variation 700 in which the endoscope 216 may be advanced andsteered to contact the portions of tissue posteriorly adjacent to thepulmonary vessels LPV, RPV such that an encircled region is formed 702.As illustrated, embodiments of the steerable endoscope of the presentinvention may be positioned about a portion of the coronary vasculatureor other coronary landmarks to facilitate treatments of the heart. Inthis specific example, the endoscope 216 has been maneuvered using thetechniques described herein into a position interior and adjacent thepulmonary veins and extended towards the inferior vena cava. The extremeconfigurability and controllability of the space and position ofsteerable endoscopes of the present invention enable placement oftherapeutic devices, elements and systems about the heart and elsewherewithin the body to facilitate treatment.

FIGS. 12A and 12D illustrate additional alternative embodiments ofsteerable endoscopic devices of the present invention advanced about theposterior region of a heart to facilitate treatment of asupraventricular tachycardia and/or combinations of supraventricular andventricular tachycardia. As described above with regard to FIGS. 10A and10B, the left pulmonary veins (LPV) and right pulmonary veins (RPV) areused as landmarks for purposes of illustration and discussion and notlimitation. FIG. 12A illustrates an endoscopic device 1200 positionedabout both the LPV and RPV and encircling one of the LPV and thenproceeding anteriorly across a ventricular portion of the heart 1205.FIG. 12B illustrates an endoscopic device 1200 positioned about both theLPV and RPV and encircling one of the LPV and then proceeding laterallyacross a ventricular portion of the heart 1210. FIG. 12C illustrates anendoscopic device 1200 positioned about both the LPV and RPV, partiallyencircling the LPV and then proceeding anteriorly across a ventricularportion of the heart 1205. FIG. 12D illustrates an embodiment of thepresent invention where two endoscopic devices 1250 and 1260 areutilized to facilitate an ablation therapy. The first steerableendoscopic device 1250 is positioned laterally across the heart andpartially encircling a LPV and a RPV. The second endoscopic device 1260is positioned adjacent a LPV, encircling a RPV and then proceedinganteriorly across a ventricular surface of the heart 1205. It is to beappreciated that the first steerable endoscope 1250 may be used tofacilitate a first ablation therapy at the same time, subsequent to orin a sequence with a second ablation therapy facilitated by the secondsteerable endoscope 1260. As these illustrative embodiments demonstrate,the steerable endoscopes of the present invention may be deployed in awide variety of circumstances to facilitate an ablation therapy.

FIG. 13 shows an embodiment of a dual, steerable endoscope 1300 of thepresent invention utilized to facilitate treatment of the heart. Thedual steerable endoscope 1300 includes a first steerable endoscope 1305and a second steerable endoscope 1310 disposed within the firststeerable endoscope 1305. In one embodiment, both endoscopes 1305, 1310are articulated to an initial condition (I). Thereafter, the secondendoscope 1310 proceeds along the pathway (a) through (i) to encirclethe LPV, RPV and then proceed across a ventricular portion of the heart.The second endoscope 1310 may proceed along the pathway under control ofa user. Alternatively, the second endoscope 1310 may proceed along thepathway by automatically deploying based upon any or a combination ofpre-surgical planning imagery, real time imagery, mapping systemreceiving inputs from a detection or tracking system. In anotheralternative, the second endoscope 1310 proceeds using a combination ofautomatic controls and user input.

While described above in an application for treating the heart, it is tobe appreciated that the first and second steerable endoscopes may beutilized to access portions of the neurovasculature, and other regionsby maintaining the size of the second steerable endoscope to be muchless than the size of the first endoscope. For example, the firstendoscope may positioned in a first position, affixed in that positionto act as a stable platform and/or datum for the second steerableendoscope. From that stable base, the second endoscope may be deployedto facilitate treatments.

FIGS. 14A to 14C shows side and end views, respectively, of variouselectrode configurations on the endoscope for tissue ablation treatment.The endoscope 900 may be configured with a number of elements, devicesor systems to facilitate treatment. In one specific embodiment, asteerable endoscope of the present invention may have a plurality ofelectrodes disposed along its outer surface to facilitate the tissueablation along the length, or selected regions of length, of theendoscope, as shown as described herein. The figure shows the steerabledistal portion 904 and part of the automatically controllable proximalportion 902 as one example of electrode placement over the endoscope900. As seen, one or any number of electrodes 906 may becircumferentially positioned, e.g., ring-shaped, along the length ofendoscope 900 at intervals. The electrodes 906 are shown positioned atuniform intervals in this variation; however, they may be configured inany random, arbitrary, or specified locations over the outer surface ofthe endoscope 900. Each of the electrodes 906 may be electricallyconnected via corresponding wires 908 to a power supply and/orcontroller. Thus, all the electrodes 906 may be configured to operatesimultaneously or to operate only selected electrodes 906 which may bein contact with tissue. In yet another variation, various ablationdevices may be delivered to the desired areas, again as described above.

FIG. 14B shows another variation in endoscope 910 in which electrodes916 may be configured to extend longitudinally over the proximal portion912 and/or distal portion 914. The electrodes may be configured toextend in a continuous strip along the endo scope length or theelectrodes 916 may be alternatively configured to extend in a segmentedmanner longitudinally over the endoscope 910, as shown. Having segmentedelectrodes 916 may allow for selected electrodes to be activated duringtissue ablation. Although FIG. 14B shows a single line of electrodes 916for illustration purposes, multiple lines of electrodes may bepositioned over the outer surface of the device, as shown in the exampleof FIG. 14C, which illustrates multiple lines of electrodes 918 spaceduniformly around the circumference of the endoscope surface.

These examples described above are intended to be illustrative and arenot intended to be limiting. Any number of other configurations may beaccomplished with the endoscopic device due to the ability of the deviceto steer and configure itself such that excessive contact withsurrounding tissue is avoided. Moreover, access to any number of variousregions within the thoracic cavity with minimal or no damage tosurrounding tissue and organs may be accomplished using the controllableendoscopic device above. Other examples for treatment using theendoscope may include, but not limited to, lead placement, implantabledevice placement, treatment on the lungs such as emphysema treatments,etc.

Depending upon the treatment being facilitated, it may be advantageousto increase the degree of contact or ensure the position between thetreatment tool, element, or device and the tissue, organ or portion ofthe body receiving the treatment. Examples of means for increasingcontact or affixing the position of a treatment device include:biocompatible adhesives, glues and gels either alone or in combinationwith staples, suction, wires, barbed and barb-less hooks or hook shapedto loop around specific anatomy. One example of a hook shaped to looparound specific anatomy includes J-shaped hooks to loop, at leastpartially, about the coronary vasculature. For example, a J-shaped hookmay be shaped and configured to at least partially encircle a pulmonaryvein. In another example, wires, staples or other fastening componentsmay be formed from shape memory alloy material such as, nitinol or othersuitable, biocompatible shape memory alloy material. The shape memoryalloy fastener could be held in a first or stowed condition whilenavigating to the site prior to facilitating treatment. Once thetreatment device is positioned, the shape memory alloy fastener could beactivated and use the shape memory effect to affix the treatment deviceinto the desired position.

In another embodiment, a steerable endoscope having a magnetic portioncould be deployed about the tissue, organ or region of the body tofacilitate treatment. Thereafter, the steerable endoscope could be usedas a guide for the placement of an ablation system. Permanent magnets orelectromagnets could be used to magnetically couple the ablation systemin a desired position adjacent the steerable endoscope. Once thetreatment was completed, the magnetic field is broken and the ablationsystem and steerable endoscope withdrawn.

In another embodiment, the steerable endoscope itself may be loopedaround the organ, tissue or portion of the body to undergo treatment andthen secured to itself in order to facilitate treatment. Alternatively,the distal end of the endoscope could be anchored with a dissolvablesuture or other dissolvable biodegradable fastener that remains in placeafter the ablation treatment is completed and is then absorbed into thetissue or dissolves.

In addition, an array of needles may be configured along the length or aportion of the length of the ablation device or steerable endoscope orboth. In one embodiment, an array of conductive needles are arranged toimprove contact between an RF ablation based delivery system and thetissue undergoing treatment. In addition to needle arrays, othersuitable elements may be employed to improve the effectiveness of otherablation modalities. It is to be appreciated therefore that while needlearrays are described as increasing the effectiveness of the delivery ofRF ablation energy, other elements and configurations may be used toincrease the effectiveness of other ablation therapy modalities.Alternatively, for non-energy based ablation, such as ablationtechniques that use lacerations of the tissue, then the elements couldbe any suitable device for cutting or otherwise altering the tissue toachieve a therapeutic affect.

FIGS. 15A and 15B show an embodiment of a needle array in a retracted(FIG. 15A) and a deployed (FIG. 15B) configuration. A portion of asteerable endoscope or ablation element 1500 is shown in cross section.Ablation needles 1505, 1510 are attached to backing plate 1515. Theneedles are maintained in the stowed configuration (FIG. 15A) with thebacking plate retracted to reduce the risk of inadvertent tissue damageas the steerable endoscope or ablation system is advanced to thetreatment site. In the stowed configuration, the needles 1505, 1510remain below the steerable endoscope or ablation element exteriorsurface 1502. Once in position, the backing plate 1515 is advanced tothe deployed condition (FIG. 15B). In the deployed position, the needles1505, 1510 protrude beyond the steerable endoscope or ablation elementexterior surface 1502. When positioned in the body for treatment, theneedles 1505, 1510 would make suitable contact with the surroundingtissue, organ or body portion to facilitate treatment.

It is to be appreciated that the backing plate may be moved between theretracted and deployed configuration utilizing any of a number oftechniques. Examples of such techniques and methods include mechanicaldrives, hydraulics, motors, actuators, permanent magnets,electromagnets, spring loaded actuators, vacuum, or other conventionalactuation means. Alternatively, the actuation means could be anysuitable actuation force capable of displacing the backing plate 1515 tourge a portion or all of a needle array from a retracted position into adeployed position and hence into suitable contact with the organ, tissueor body portion to receive treatment.

In an alternative embodiment, the backing plate 1515 could becontinuously biased outwardly, here, outwardly indicates a positionwhere the needles would move into a deployed configuration. The ablationelement or steerable endoscope having the needle array could be coveredwith a moveable sheath. Once the ablation element or moveable endoscopeis in the desired position, the sheath is retracted releasing thebacking plate bias and allowing the needles to move into a deployedconfiguration.

The illustrated embodiment illustrates a pair of needles in crosssection. There may be additional needles arranged adjacent and similarlydisposed as the needles 1505, 1510. The additional needles may be, forexample, arrayed in a regular continuous pattern as in FIG. 16.Alternatively, a single needle or array on continuous, discontinuous orrandom arrangement of needles may be used. In other configurations, morethan teo needles may be used. The illustrated needles 1505, 1510 have aseparation angle ϕ₁. The separation angle may vary from 0 to 180 degreesin one embodiment, from 0 to 70 degrees in another embodiment or from0-30 degrees in yet another embodiment depending upon application. Inmultiple needle applications (i.e., needle arrays having two or moreseparation angles), the needles may have a regular separation anglemeaning that the needles are at regular angular intervals.Alternatively, the needles in a multiple needle configuration may beplaced in non-regular or variable separation angles.

In addition to the angular placement of the needles in a needle array,the spacing between needles may also be continuous or variable. Theneedles may be arranged into a single continuous segment with uniformspacing. Such a uniform array of needles is illustrated in FIG. 16. Theablation element or steerable endoscope section configured for ablation1600 is shown in FIG. 16. Needles 1610 are shown in a single segment orgrouping of needles 1605.

FIG. 17 shows an embodiment of a needle array segment 1700 having threesections (1705, 1710 and 1715) showing a variety of needle spacingconfigurations. The needle array segment 1700 illustrates how a nearlylimitless variety of spacing configurations may be combined to obtain adesired needle array configuration to facilitate an ablation treatment.Section 1705 includes an upper array of needles 1726, 1728 and 1730aligned in a continuous uniform fashion above a lower array of needles1720, 1722 and 1724. This configuration is similar to section 1600 inFIG. 16. Like section 1705; the upper array of section 1710 has evenlyspaced needles 1732, 1734 and 1736. The lower array of needles have onlyone needle aligned to the upper array. Needle 1738 is aligned withneedle 1732. There is no needle in the lower array that corresponds toneedle 1736. A plurality of needles (1740, 1741 and 1742) are spacedacross from upper array needle 1734. The section 1710 illustrates howthere may be needle to needle correspondence (1732, 1738), nocorrespondence (1736) or one to many correspondence (1734, 1740, 1741,1742) between the needles in the upper and lower arrays of a section.

Section 1715 further illustrates the configurability of the needlearrangements. Both the upper needles 1750, 1752, 1754 1756 and lowerneedles 1766, 1768, 1770, 1771, 1772, 1773 illustrate variable spacing.In addition, there is no alignment between the upper and lower arrays.In addition, section 1715 illustrates a middle array having upperneedles 1758, 1760 spaced apart from lower needles 1762, 1764. In theillustrated embodiment, the upper and lower needles are aligned but thatneed not be the case in all embodiments. Additionally, the middle arrayis illustrated without alignment to the upper array and the lower array.This need not be the case in all embodiments. In some embodiments, themiddle array may be aligned with all or part of either a lower or anupper array. Accordingly, a needle pattern within a section could bepredetermined and selected to facilitate a desired ablation treatment.Moreover, using pre-surgical planning techniques, the type, number,amount and ablation pattern could be predetermined and an appropriatecombination of segments, sections and needles arrays could be loadedinto a steerable endoscope or otherwise delivered utilizing a steerableendoscope to facilitate treatment.

FIGS. 18A and 18B show a side and isometric view of an embodiment of atunable treatment device of the present invention. The tunable treatmentdevice 1800 includes an ablation element 1810 within a housing 1805. Thehousing 1805 also includes an opening 1815 that allows the energygenerated by the ablation element 1810 to pass outside of the housing.The opening 1815 is fitted with a cover 1820 that forms a seal betweenthe environment the tunable treatment device 1800 is positioned in andthe interior of the housing 1805. In one embodiment, the housing 1805 ismade of a first material and the cover 1820 is made of a secondmaterial. With respect to the energy generated or provided by theablation element 1810, the first material transmits less of the energygenerated by the ablation element 1810 than the second material. Inanother embodiment, the first material acts as a shield separating theablation energy generated by the ablation element and the surroundingenvironment. The second material acts as a transmission window oropening in an otherwise shielded housing. The transmission window oropening thus allows energy provided by the ablation element to beselectively passed via the opening into the tissue, organ or environmentpositioned adjacent the cover 1820. Thus, the advantageous combinationof shielding and openings allow for more precise delivery of theablation energy to the desired tissue, organ or location while shieldingthe surrounding area from the ablation energy.

The tunable ablation delivery device 1800 is also provided with adetector 1830 for detecting a physiological indication useful inadministering the ablation therapy. The detector 1830 may comprise aplurality of detection elements arrayed about the housing 1805. In theillustrated embodiment, the detector 1830 includes a plurality ofdetection elements 1835. The detection elements 1835 are arranged atregular intervals about the perimeter of the housing 1805. A reading maybe obtained from each element and then analyzed to determine whichelement or elements obtained the best reading for the physiologicalparameter being measured. Once that determination is made, the tunableablation device 1800 may then be oriented to place the opening 1815 intoposition to facilitate ablation treatment.

In one specific example, the tunable ablation delivery device 1800 maybe modified to facilitate an ablation treatment on the pericardium ofthe heart. In this example, the detection elements 1835 may be elementscapable of detecting electrophysiological (EP) activity. For example,the detection elements 1835 could detect electrophysiological (EP)activity by detecting ECG activity. An example of the readings and/orsignal strength obtained by each detector 1835 is illustrated in FIG.19. FIG. 19 shows a graph illustrating a technique to optimize placementof a tunable ablation device to facilitate therapy. Using conventionalsoftware, hardware and optimization techniques, the detection elements1835 may be used to localize the position, relative to the housing 1805,where the desired amount of physiological indication occurs. In thegraph 1900 the desired activity is the peak EP activity. According tothe graph 1900, the peak EP activity occurs in proximity to sensorposition 5. This information can then be used by the control system thatarticulates, rotates, translates or otherwise positions the tunableablation element 1800 to position the tunable ablation element 1800 intoa position that facilitates an ablation treatment in the vicinity ofsensor 5. In the specific embodiment illustrated in FIGS. 18A and 18B,the tunable ablation device 1800 would be rotated under the control of acontrol system having the relative position and orientation of theplurality of elements 1835 and the opening 1815 and ablation element1810. The tunable ablation device 1800 would be rotated under thecontrol of a control system using for example, the engagement element1845, to align the opening 1815 and/or cover 1820 into the orientationof sensor 5.

An example of how a plurality of tunable ablation elements may beadvantageously deployed to increase the effectiveness of an ablationtherapy will now be described with reference to FIGS. 18C and 18D. Threetunable ablation elements 1800A, 1800B and 1800C are positioned within asteerable endoscope 212 of the present invention. In FIG. 18C the threeablation elements have reached the deployment point for ablation element1800A. Note that in the initial position before optimizing any of thetunable ablation elements 1800A, B or C, the windows 1820 are aligned.As described above the detectors 1830 on ablation element 1800A are usedto improve the effectiveness of the ablation element within the tunableablation element 1800A by indicating a desired position for applying theablation therapy. As shown in FIG. 18B, the determined position of theelement 1800A is when the window 1820 rotated into a slightly upwardposition from the initial position. Additionally, the mechanical linkage1845 has been disengaged so that the control cable/component 1880 nolonger rotates the element 1800A. In addition, the fixation elements forelement 1800A have been omitted for clarity but have engaged to fix theposition of element 1800A. FIG. 18D also illustrates how the controllercable/component 1880 has utilized the detector 1830 onboard element1800B to optimize the position of the window 1820. Note that the window1820 for element 1800B is rotated downward. At this point, the fixationelements for element 1800B are engaged to fix the position of theelement 1800B. Thereafter, the linkage 1845 for element 1800B isreleased so that element 1800C may be positioned and then optimized asdescribed herein for elements 1800A and 1800B. Accordingly, there areconfigurations of the tunable ablation elements where the windows ofadjacent ablation elements are not in alignment but rather reflect analignment of localized optimization for that ablation element.

In an alternative embodiment, the detector for detecting a physiologicalindication could also be a single detector. The single detector could beactuated to move about the surface of the tunable ablation deliverydevice 1800 measuring the indication. The obtained measurements couldthen be used to assist in positioning the ablation element 1810 andopening 1815 to facilitate treatment. In one specific embodiment, thesingle detector could move about the perimeter of the tunable ablationdevice and provide strength of indication relative to positioninformation similar to FIG. 19.

A securing member 1840 is also provided to hold the tunable ablationdevice 1800 in the desired position during the readings from theindicator elements 1835, or after rotation of the ablation device intothe desired position for facilitating treatment. In the illustratedembodiment, the securing member 1840 may be a vacuum manifold 1855having a plurality of suction ports 1860. In a preferred embodiment, thesecuring means is releasable from the surrounding tissue, organ orregion of interest to facilitate movement to align the ablation elementfor treatment or for easy removal once the treatment is complete.

The endoscope device may also be utilized for procedures within theperitoneal cavity. Potential applications may include minimally invasivesurgery for urologic, bariatric, and liver surgery. Moreover, minimallyinvasive access may be achieved for treatments in spinal or orthopedicsurgery as well. FIG. 20 shows an example of a procedure 2000 within theperitoneal cavity which may be performed with the endoscopic device.FIG. 20 shows an example of a procedure 2000 within the peritonealcavity using the endoscopic device 212. The endoscope 212 may beintroduced into patient 2002 through an incision 2008 via a port, whichmay also function as a datum 2006, as described above. The distalportion 214 may be steered to avoid various organs while being 2004. Thedistal portion 214 of the endoscope 212 may accordingly be steered whilethe proximal portion 216 may be automatically controlled to follow apath defined by the distal portion 214 which minimizes contact with thesurrounding and adjacent tissue and organs. One or more laparoscopes2010 may optionally be used in combination with the endoscope 212 toassist with the surgical procedure. Once the distal portion 214 isposteriorly positioned of the liver 2004, various tools or treatmentdevices may be advanced through the endoscope 212 from the proximal endto effect the desired treatment. Although this example shows treatmentof the liver 2004 using the endoscope 212, this is intended to beillustrative of other organs or procedures that may be effectivelytreated utilizing embodiments of the endoscope 212.

As the above discussion illustrates, steerable endoscopic systems of thepresent invention may be advantageously utilized to facilitate a widevariety of procedures. When utilized to facilitate an ablation therapy,the ablation element, device or system may be part of the segmentedsteerable endoscope, deployed within a working channel or other passagecreated by the steerable endoscope, or a combination of fixed andmoveable treatment elements, device or systems. Accordingly, steerableendoscopes of the present invention may, in one embodiment, facilitatetreatment by deploying an ablation element, device or system affixed tothe endoscope to a treatment location in a treatment position. Theendoscope remains in place during the treatment and, when complete,retracts from the treatment position.

In another variation, the steerable endoscope is utilized to deployand/or inspect the placement of a treatment device, is then withdrawnwhile the treatment proceeds. Thereafter, the steerable endoscoperetrieves the treatment device. In yet another variation, the steerableendoscope may be inserted into a treatment area into a desired treatmentpathway. Next, the steerable endoscope is retracted to leave thetreatment device in place along the desired treatment pathway. Thesteerable endoscope may remain in place for visualization of thetreatment as it proceeds, monitor a physiological indication orotherwise support the treatment. Alternatively, the steerable endoscopemay withdraw from the treatment area or completely from the body. Afterthe treatment is complete, the steerable endoscope may be advanced alongthe treatment device to remove/store the treatment device as theendoscope proceeds distally along the treatment device. Once thetreatment device has been collected into the endoscope, the endoscope iswithdrawn. Accordingly, there have been shown various ways to position atreatment element, device or system within a body, affix or otherwisemaintain the position of the treatment device relative to the area orareas of treatment to increase the effectiveness of the treatment ortherapy being performed.

Separately or in combination with the techniques described above,various imaging and control systems may be used to facilitate control ofthe steerable endoscope. For example, the steerable endoscope mayproceed along and envelope a deployed treatment device utilizing arecorded pathway to retrace steps used to place the treatment device.The steerable endoscope may also track a way point set to indicate thenext fastener where the fastener is in a preprogrammed position, in aposition identifiable using an imaging system or the fastener isotherwise configured for easy identification, such as through use of anRPID, for example. The steerable endoscope may also use an imagingsystem for guidance in recovering a treatment device. The steerableendoscope may also utilize fly by wire techniques to fly by wire usingthe treatment device as the wire. In yet another embodiment, thetreatment device could be automatically withdrawn into the steerableendoscope using mapping, imaging or other system controls to retracetrack or otherwise dislodge or disengage the treatment device from theinternal position to perform a treatment.

Embodiments of the present invention may also include tools, devices orsystems to pierce, lacerate, cut, puncture, or otherwise provide apassage or controlled perforation of tissue to allow access of thesteerable, guided endoscope into the region of interest. In aneurological application for accessing the brain, such a device would besuited for creating a suitable opening in the dura for example. In acardiovascular application for accessing the heart, such a device wouldbe suited for creating a suitable opening in the pericardium forexample. The tools, devices or systems to pierce, lacerate, cut,puncture, or otherwise provide a passage or controlled perforation toenable passage of the endoscope may be disposed permanently on thedistal end of the scope. Alternatively, the tools, devices or systemsmay be mounted on the distal end of the endoscope but be positionablebetween a retracted and extended position to help minimize the risk ofinadvertent damage while the endoscope is moving within the body to theregion of interest. In another alternative, the tools, devices orsystems may be provided conventionally via a working channel in theendoscope. Examples of the tools, devices or systems include scissors,electrocautery devices and systems, small snips, shaped blades andshaped tips.

While embodiments of the present invention have been shown and describedas dispensing treatment within the brain, cranial interior, the interiorof the heart, the exterior of the heart, it is to be appreciated thatembodiments of the methods and apparatus of the present invention may beused in other applications as well. For example, embodiments of theinvention may be used to facilitate treatment of disorders of otherorgans and portions of the body, for example, the stomach, thegastrointestinal tract, the esophagus, the bladder, the liver, thekidneys and the lungs. Additionally, embodiments of the presentinvention may be used to facilitate treatment of localized disorderswithin the body, portions of the body or a disorder of a physiologicalsystem.

The applications of the devices and methods discussed above are notlimited to regions of the body but may include any number of furthertreatment applications. Other treatment sites may include other areas orregions of the body. Additionally, the present invention may be used inother industrial and commercial environments such as exploratoryprocedures on piping systems, ducts, internal inspection of mechanicalsystems including automotive, aeronautical, aerospace, and marinesystems and equipment, etc. Modification of the above-describedassemblies and methods for carrying out the invention, and variations ofaspects of the invention that are obvious to those of skill in the artare attended to within the scope of the claims.

The invention claimed is:
 1. A surgical system comprising: a firstelongate device and a second elongate device, each of the first elongatedevice and the second elongate device having a steerable distal portionand a proximal portion, wherein the second elongate device is disposedat least partially within the first elongate device and is configured toextend and retract relative to the first elongate device; a positionsystem comprising a sensor configured to sense a position of at leastone of the first elongate device and the second elongate device; and acontroller configured to: receive user input, receive sensed positioninformation from the positioning system, receive information identifyinga location within a body, and control movement of at least one of thefirst elongate device and the second elongate device along a pathway toreach the location in the body based on the user input and the receivedsensed position information, and maintain a portion of the at least oneof the first elongate device and the second elongate device at thelocation.
 2. The surgical system of claim 1, wherein the controller isfurther configured to automatically maintain the portion of the at leastone of the first elongate device and the second elongate device at thelocation.
 3. The surgical system of claim 1, wherein the sensor of thepositioning system is configured to produce a signal indicative of thelocation of the portion of the at least one of the first elongate deviceand the second elongate device with regard to a point of reference. 4.The surgical system of claim 1, wherein the controller is furtherconfigured to receive image data correlating the location within thebody and a frame of reference.
 5. The surgical system of claim 1,wherein the sensor of the position system is configured to detect achange in position of the at least one of the first elongate device andthe second elongate device.
 6. The surgical system of claim 1, whereinthe controller is further configured to control the movement of the atleast one of the first elongate device and the second elongate device tomaintain the at least one of the first elongate device and the secondelongate device in a predetermined fixed position.
 7. The surgicalsystem of claim 1, wherein the surgical system further comprises animaging device to image the location within the body.
 8. The surgicalsystem of claim 1, wherein the controller is further configured torecord the movement of the at least one of the first elongate device andthe second elongate device along the pathway.
 9. The surgical system ofclaim 1, wherein the information identifying the location within thebody is chosen from at least one of position, location, tissue type, anddisease state.
 10. The surgical system of claim 1, wherein the firstelongate device and the second elongate device each comprise steerableendoscopes.
 11. The surgical system of claim 1, wherein the secondelongate device is configured to traverse along a path defined at leastpartially within the first elongate device.
 12. The surgical system ofclaim 11, wherein the controller is further configured to control themovement of the second elongate device traversing along the path definedwithin the first elongate device.
 13. The surgical system of claim 1,wherein the controller is configured to maintain the position of thefirst elongate device while the second elongate device extends from thefirst elongate device to perform a treatment within the body at thelocation.
 14. The surgical system of claim 1, wherein the sensorcomprises a motion transducer configured to measure at least one ofaxial and rotational displacement of the at least one of the firstelongate device and the second elongate device.
 15. The surgical systemof claim 1, wherein the second elongate device comprises a surgical toolto perform a surgical procedure.
 16. The surgical system of claim 15,wherein the surgical tool comprises an ablation element.